(5 & 6) Fractures Flashcards
What are the two types of fracture healing?
Secondary & Primary
What are the four stages of secondary healing?
- 1: Inflammation and haematoma formation (1-5 days)
- 2: Formation of cartilaginous (soft) callus (5-11 days)
- 3: Formation of bony (hard) callus (11-28 days)
- 4: Bone remodeling (day 21 to months)
What occurs during stage 1 of inflammation and haematoma formation?
- directly after injury
- haematoma forms from cells of bone marrow, peripheral blood, & intramedullary blood
- coagulates & forms b/t fracture ends
- scaffold for callus
What happens during stage 2 of formation of cartilaginous (soft) callus?
- platelets recruited to fracture site
- triggers inflammatory response
- brings fibroblasts to site
- lay down collagen rich fibrocartilaginous network across fracture site
- blood vessel production
What happens during stage 3 in the formation of bony (hard) callus
- fibroblasts differentiate into osteoblasts
- commence process of new bone formation adjacent to fracture ends
- conversion cartilaginous callus to bone
- bony material produced is cancellous
What happens during stage 4 in bone remodeling?
- osteoclasts & osteoblasts begin remodeling hard callus
- called ‘coupled remodeling’
- cancellous bone converted to lamellar bone
What is primary healing?
- no distinct stages
- occurs when there is a mechanical continuity between fracture fragments (no gap)
- facilitated by bridging units “cutting cones”
How do “cutting cones” work in primary healing?
- osteoclasts at tip of cones resorb cortical bone
- creates longitudinal cavities b/t them
- osteoclast & osteoblast activity and formed at nearest site injury
- osteoblasts behind osteoclasts produce new bone, filling cavity
- bridges fracture gap
When does secondary healing most commonly occur?
- most common in non-op
- can occur within surgical fixation
- does not require anatomic reduction
- most fractures heal this way
When does primary healing most commonly occur?
- result rigid, anatomic reduction of bone fragments
- not commonly result natural process
- requires fracture ends to be reduced
- occurs following surgical reduction & fixation
What is the effect of immobility / bedrest on older patients?
- up to 15% drop VO2max & 30% drop FRC after 1 week
- 25% drop circulatory volume after 1 week
- 20% drop muscle strength after 1 week
- decline in walking ability ~2 days
- 50% incontinent ~1 day
What is the Irish Hip Fracture Database?
- monitors performance of 16 hospitals performing hip fracture surgery in ROI
- 7 standards to be met
What are the 7 standards of the IHFD?
- patient orthopaedic ward within 4 hours of admission
- surgery within 48 hours
- minimise risk of pressure ulcers
- routine geriatrician
- bone health assessment
- special falls assessment
- mobilisation on day of/after surgery by a physio
What are the 4 types of hip fracture?
- Intracapsular
- Extracapsular
- Intertrochanteric
- Subtrochanteric
What is a hemiarthroplasty?
partial hip replacement procedure that involves replacing only the ball portion of the hip joint, not the socket
What are the CSP (2018) hip fracture rehab guidelines?
- physio Ax and mobs day of/after surgery
- at least 2 hours physio in first week
- at least 2 hours rehab in subsequent weeks
- strength, balance, transfers & walking
What are the APTA (2021) hip fracture rehab guidelines?
- transfer out bed asap after surgery & daily
- structured exercise including progressive, resistive strength, balance, WB & functional mobility
- dynamometry, gait speed test, TUG, CAS
What is the physio’s role in exercise rehab?
- check WB status
- screen & establish baseline
- home exercise program (HEP)
- dress patient & transfer out of bed
- discharge planning
- outcome measures
- follow-up following discharge
What should be considered for home discharge patients?
- not living alone
- fell outdoors
- walking aid
- do not have dementia
- low ASA score
- no major co-morbidities
How do distal femur fractures occur?
- fall from standing (elderly)
- high-energy trauma (young males)
What is the physio management for a distal femur fracture?
- mobility education as per WB status
- wean from aids when possible
- while in brace, focus on ankle ROM, isometric quads, standing gluteal sets
- when brace off, ROM to full then stationary bike
- open & closed chain proprioception
- plyometrics as per guidelines
What causes patella fractures?
- direct impact to patella
- indirect eccentric contraction
What is the physio management for a fractured patella?
- mobility education as per WB status
- wean from aids once allowed
- while in cast focus ankle ROM, isometric quads & standing gluteal
- ROM to full then stationary bike
- open & closed chain proprioception
- plyometrics as per guidelines
How are tibial plateau fractures scaled?
- Schatzker Classification
- 1-6
- Higher number means higher severity
What is the physio management for a tibial plateau fracture?
- initially always NWB
- gait education with walking aid
- HEP: static quads & glutes, SLR, ankle ROM
- active knee ROM once brace off
- progressive knee ROM
- closed chain strength hip, knee, ankle
- progress FWB and wean aids
- proprioception and functional
How do fractures of the tibia occur?
- high energy in young patients (fall from height, RTC, sport)
- low energy in elderly (fall from standing height)
When is external fixation useful?
- malunion or non-union
- after soft tissue flap construction
- mgmt fractures in patients with fragile skin
- treatment fractures with significant bone loss
What is the physio management for a fractured tibia?
- mobility education as per WB status
- ankle & knee ROM
- quads and gluteal sets
- wean from aids once able
- ROM restoration through exercise program & manual T
- open & closed chain resistance programme
- proprioception & plyos
What are the two ankle fracture classifications?
- Dans-Weber
- Lauge-Hansen
What are the Dans-Weber classifications of ankle fracture?
- classifies distal fibula fractures according to position
A. below ankle syndesmosis
B. at level ankle syndesmosis
C. above ankle syndesmosis
What are the Lauge-Hansen classifications of ankle fracture?
- classifies according to position of joint at injury
1. Supination-External Rotation
2. Pronation-External Rotation
3. Supination-Adduction
4. Pronation-Abduction
What is the physio management during the immobilisation period of an ankle fracture?
- FWB immediately in cast/boot
- mobility education based on WB status
- Knee ROM
- quads & gluteal sets
What is the physio management after the immobilisation period of an ankle fracture?
- ROM restoration through exercise program & manual therapy
- open & closed chain resistance program for calves
- wean from aids and restore gait
- proprioception & plyos
How does a calcaneus fracture occur?
usually a fall from height
How does a metatarsal fracture commonly occur?
- crush injury
- hindfoot / leg rotation on fixed forefoot
What is the physio management for foot fractures?
- mobility education as per weight bearing status
- for calcaneus, treated like an ankle fracture once out of immobilisation
- for metatarsal, little physio treatment apart from gait education & advice
